NCLEX Fundamentals of Nursing Quiz

Questions and Answers

In the United States, the first programs for training nurses were affiliated with:

General hospitals

Civil service

Religious orders (correct)

The military

Which of the following is/are an example(s) of a health restoration activity? (Select all that apply)

Assessing a client's surgical incision (correct)

Advising a woman to get an annual mammogram after age 50 years

Teaching the importance of hand washing

Administering an antibiotic every day (correct)

Which of the following aspects of nursing is essential to defining it as both a profession and a discipline?

Professional organizations

Activities determined by a scope of practice

Established standards of care

Practice supported by scientific research (correct)

The charge nurse on the medical surgical floor assigns vital signs to the nursing assistive personnel (NAP) and medication administration to the licensed vocational nurse (LVN). Which nursing model of care is this floor following?

Functional nursing Signup and view all the answers

A patient who suffered a stroke has difficulty swallowing. Which healthcare team member should be consulted to assess the patient's risk for aspiration?

Speech therapist Signup and view all the answers

Which of the following is/are an example(s) of theoretical knowledge as defined in this chapter? (Select all that apply)

In Maslow's framework, physical needs are most basic. Signup and view all the answers

Critical thinking and the nursing process have which of the following in common? Both:

Are important to use in nursing practice Signup and view all the answers

In which step of the nursing process does the nurse analyze data and identify client problems?

Diagnosis Signup and view all the answers

In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem?

Evaluation Signup and view all the answers

What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to:

Identify personal biases that may affect his thinking and actions Signup and view all the answers

Arrange the steps of the nursing process in the sequence in which they generally occur.

A, E, C, D, B Signup and view all the answers

How are critical thinking skills and critical thinking attitudes similar? Both are:

Influences on the nurse's problem solving and decision making Signup and view all the answers

The nurse is preparing to admit a patient from the emergency department. This best illustrates:

Self-knowledge Signup and view all the answers

Which organization's standards require that all patients be assessed specifically for pain?

The Joint Commission Signup and view all the answers

Which of the following is an example of data that should be validated?

The client states she feels feverish; you measure the oral temperature at 98°F. Signup and view all the answers

Which of the following is an example of appropriate behavior when conducting a client interview?

Sitting, facing the client in a chair at the client's bedside, using active listening Signup and view all the answers

The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data collection form organized according to (select all that apply):

Gordon's functional health patterns Signup and view all the answers

The nurse is recording assessment data. Which errors did the nurse make? (Select all that apply)

Recorded an inference rather than a cue Signup and view all the answers

A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing?

Focused physical assessment Signup and view all the answers

The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, how should the nurse position the patient for this portion of the admission assessment?

Sitting upright Signup and view all the answers

What should a child do when encountering a gun?

Leave the area and tell an adult Signup and view all the answers

What should a nurse do next for an agitated patient who cannot be reoriented?

Provide comfort measures Signup and view all the answers

What should the nurse do first if a person is clutching his throat?

Ask, 'Are you choking?' Signup and view all the answers

What should parents do to promote child safety in the home?

Store firearms unloaded and out of sight Signup and view all the answers

What is the leading cause of unintentional death in the U.S. population?

Motor vehicle accidents Signup and view all the answers

Which change in hygiene practices may be necessary as the patient ages?

Bathing every other day Signup and view all the answers

Which healthcare team member can bathe a female patient of Orthodox Jewish faith?

Female graduate nurse Signup and view all the answers

What factor places a client at risk for impaired skin integrity?

Dehydration Signup and view all the answers

How should a nurse document a lesion caused by tissue compression?

Pressure ulcer Signup and view all the answers

How should nursing assistive personnel proceed with a bag bath for a patient?

Bathe the entire body using 8 to 10 washcloths Signup and view all the answers

Which intervention should a nurse choose for a morbidly obese patient to counteract pressure from skin folds?

Keep the linens wrinkle free Signup and view all the answers

Which is considered a primary defense against infection?

Intact skin Signup and view all the answers

Which rule must be observed to follow contact precautions?

A clean gown and gloves must be worn Signup and view all the answers

Which client can be safely paired with a client in protective isolation?

Admitted with unstable diabetes mellitus Signup and view all the answers

Which action demonstrates a break in sterile technique?

Reaching 1 foot over the sterile field Signup and view all the answers

A mother breastfeeding her child passes on which antibody?

IgG Signup and view all the answers

What is the rationale for hand washing?

Remove transient flora from the skin Signup and view all the answers

Which incident requires the nurse to complete an occurrence report?

Patient's dentures lost after transfer Signup and view all the answers

What best describes source-oriented charting?

Separates the health record according to discipline Signup and view all the answers

Which abbreviation can the nurse use to document that a patient has no known allergies?

NKA Signup and view all the answers

What best describes nursing assessment flow sheets?

Comprehensive charting forms that integrate assessments and nursing actions Signup and view all the answers

What should a nurse do if she forgot to document a dressing change?

Make a late entry as an addition to the narrative notes Signup and view all the answers

What is the rationale for using an electronic health record (EHR) system?

Improves interdisciplinary collaboration to enhance efficiency Signup and view all the answers

Based on his injury, which type of pain is this patient most likely experiencing?

Phantom Signup and view all the answers

Which pain management task can the nurse safely delegate to nursing assistive personnel?

Asking about pain during vital signs Signup and view all the answers

Which factor in the patient's past medical history dictates that the nurse exercise caution when administering acetaminophen (Tylenol)?

Hepatitis B Signup and view all the answers

Which action should the nurse take before administering morphine 4.0 mg intravenously to a patient complaining of incisional pain?

Assess the patient's incision. Signup and view all the answers

Which action should the nurse take when preparing patient-controlled analgesia for a postoperative patient?

Caution the patient to limit the number of times he presses the dosing button. Signup and view all the answers

Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis?

Ibuprofen (Motrin) Signup and view all the answers

Which complication is the patient most likely experiencing with nausea and loss of motor function after receiving epidural analgesia?

Epidural catheter migration Signup and view all the answers

Which client's breath sounds require immediate medical attention?

Wheezes Signup and view all the answers

Based on the assessment finding of a pulse volume of 1, what should the nurse also assess?

Blood pressure Signup and view all the answers

Which of the following clients has indications of orthostatic hypotension?

146/88 when lying down and 130/78 when standing, and reports feeling dizzy Signup and view all the answers

Which method of taking a temperature would be most appropriate for a client who has experienced prolonged exposure to cold?

Rectal with an electronic thermometer Signup and view all the answers

Which of the following clients would have the most difficulty maintaining thermoregulation?

Young child playing soccer during the summer Signup and view all the answers

Which of the following clients should have an apical pulse taken?

An infant with no history of cardiac defect Signup and view all the answers

Which situation requires intrapersonal communication?

Staff meetings Signup and view all the answers

What is the best environment to discuss the possibility of abusive events with a patient?

An empty corner at the nurse's station Signup and view all the answers

Which goal is most appropriate for the orientation phase of the nurse-patient relationship?

Openly express his concerns about the hospitalization. Signup and view all the answers

Which type of group has been organized for people coping with the death of a loved one?

Work-related social support group Signup and view all the answers

Which response by the nurse is best when a mother asks about her son involved in a motor vehicle accident?

Don't worry, I'm sure he'll be fine; we have an excellent trauma team caring for him. Signup and view all the answers

What step should a child take first if he sees a gun at a friend's house?

Leave the area. Signup and view all the answers

Study Notes

Pain Assessment and Management

Deep somatic pain arises from injuries to ligaments, tendons, nerves, blood vessels, and bones.
Asking about a patient's pain can be delegated to nursing assistive personnel during vital sign checks.
Acetaminophen poses hepatotoxic risks in patients with liver diseases, such as hepatitis B.
Assessing respiratory status is crucial before administering opioids like morphine due to the risk of respiratory depression.
A second nurse should verify the setup of patient-controlled analgesia to prevent dosing errors.

Medication Administration Guidelines

Codeine's peak effect occurs 60 minutes post oral administration, requiring reassessment of pain.
Aspirin is the only NSAID listed that inhibits platelet aggregation, useful in patients at risk for thrombophlebitis.
Epidural catheter migration can cause nausea, motor function loss, and low blood pressure post-anesthesia.

Vital Signs and Patient Assessment

A drop in blood pressure exceeding 10 mm Hg upon standing indicates postural hypotension.
Stridor indicates possible airway obstruction and requires immediate attention, unlike other sounds such as crackles or wheezes.
Assessing blood pressure is vital when weak pedal pulses are observed to determine potential circulatory issues.

Nursing Communication and Patient Interaction

Intrapersonal communication includes self-talk, essential for a nurse’s self-assessment and motivation.
Sensitive discussions about abuse should occur in private, non-threatening environments to ensure patient comfort.
Orientation phase of nurse-patient interaction involves introducing oneself and addressing immediate needs of comfort and safety.

Group Dynamics and Health Management

Therapy groups provide support for emotional issues, such as grief, unlike task-oriented or community committees.
The nurse’s response to family members in distress should provide accurate information to alleviate anxiety and suspense.

Patient Safety and Emergency Response

Individuals with orthostatic hypotension or dizziness present fall risks and require careful monitoring.
Instruct children to stop and assess the situation if they encounter a firearm, prioritizing safety first.
When addressing agitation in patients, comfort measures should be considered before restraints, as agitation may stem from discomfort.

Emergency Protocols

If someone is clutching their throat, immediately ask if they are choking to assess the situation before taking further action.### Child Safety in the Home
Install window guards to prevent falls; never leave windows wide open.
Attaching a pacifier with a ribbon poses asphyxiation risks for infants.
Whole grapes can pose choking hazards for young children; snacks should be appropriate for age.
Firearms should be stored unloaded and out of reach, ideally in a locked cabinet.

Leading Cause of Unintentional Death

Motor vehicle accidents rank as the leading cause of unintentional death in the U.S.
Other causes include poisoning, falls, and drowning.

Hygiene Practices in Aging

Older adults may need to bathe every other day due to decreased activity of sebaceous glands, leading to dryer skin.
Increased use of moisturizers is recommended; reduce soap use to prevent further skin drying.
Maintaining regular dental hygiene remains essential regardless of age.

Cultural Sensitivity in Healthcare

Patients of Orthodox Jewish faith should receive personal care only from same-sex healthcare providers due to religious beliefs.

Risk for Impaired Skin Integrity

Dehydration increases the risk for impaired skin integrity by causing skin to dry and crack.
Body weight and stature do not contribute to risk in a patient of normal height and weight.

Documentation of Skin Lesions

Document lesions from tissue compression as pressure ulcers.
Other types of lesions include abrasions and excoriation, each defined by their causative factors.

Bag Bath Procedure

A bag bath involves using 8-10 washcloths to cleanse the patient’s body comprehensively.
It is not performed in a chair or bathtub but is an effective method for bed-bound patients.

Care for Morbidly Obese Patients

Keeping linens wrinkle-free helps alleviate pressure from skin folds, a crucial consideration in morbidly obese patients.

Primary Defenses Against Infection

Intact skin serves as a primary defense against infection, while other responses like fever and inflammation are secondary defenses.

Contact Precautions

Wear clean gowns and gloves when engaging with patients under contact precautions to prevent the spread of infection.

Safe Client Pairing in Protective Isolation

Patients free from infection, such as those with unstable diabetes, can be safely paired with others in protective isolation.

Sterile Technique

Avoid reaching over sterile fields, as this breaks sterile technique. Maintain distance from nonsterile areas.

Antibodies in Breast Milk

Breastfeeding transfers the IgG antibody to the child, providing passive immunity during infancy.

Purpose of Hand Washing

Hand washing primarily removes transient flora from the skin, preventing infections and cross-contamination.

Occurrence Reporting

An occurrence report is necessary for lost patient items, while other incidents like medication timing or equipment issues may not require one.

Source-Oriented Charting

This method separates health records by discipline, allowing clear organization of documentation.

Documenting Patient Allergies

Use "NKA" (no known allergies) to denote absence of allergies in patient documentation.

Nursing Assessment Flow Sheets

Flow sheets integrate assessments and nursing actions, allowing for efficient documentation by body systems.

Late Entry in Documentation

If a procedure like a dressing change is omitted in documentation, a late entry should be made rather than altering previous notes.

Rationale for Electronic Health Records (EHR)

EHR systems enhance interdisciplinary collaboration and improve procedural efficiency, supporting better patient care.

History of Nursing Training

The first nursing programs in the U.S. were affiliated with religious orders, providing foundational training before the establishment of general hospitals.

Health Restoration Activities

Administering antibiotics and assessing surgical incisions qualify as health restoration activities, aimed at returning patients to health.

Defining Nursing as a Profession

Professional nursing practice is based on scientific research, establishing its credibility as a discipline and a profession.

Nursing Care Models

Functional nursing model divides tasks according to staff roles; e.g., NAP handles vital signs while LVNs administer medications.

Assessing Aspiration Risks

Healthcare team members, particularly speech therapists, should be consulted for assessing patients with swallowing difficulties to guard against aspiration.### Health Professionals
Respiratory Therapist: Cares for patients with respiratory disorders.
Occupational Therapist: Helps patients regain function and independence.
Dentist: Diagnoses and treats dental disorders.
Speech Therapist: Assists clients with swallowing and speech disturbances; assesses aspiration risks and recommends treatment plans.

Theoretical Knowledge in Nursing

Example of theoretical knowledge includes facts such as "Antibiotics are ineffective in treating viral infections."
Principles from established theories, like "In Maslow's framework, physical needs are most basic," also qualify as theoretical knowledge.
Practical knowledge consists of instructions like measuring blood pressure and medication administration techniques.

Critical Thinking in Nursing

Critical thinking and the nursing process are essential in nursing practice.
The nursing process includes specific steps, while critical thinking is a more general skill applicable across disciplines.

Nursing Process Steps

The nursing process involves Assessment, Diagnosis, Planning Outcomes, Planning Interventions, and Evaluation.
Diagnosis Phase: Analyzes data and identifies client problems.
Evaluation Phase: Determines the effectiveness of interventions.

Importance of Self-Knowledge for Nurses

Self-knowledge helps nurses identify personal biases that could affect their thinking and actions, which is fundamental in delivering unbiased patient care.

Nursing Diagnoses

Identify nursing diagnoses using frameworks like Maslow's hierarchy and Gordon's functional health patterns for comprehensive understanding of patient needs.

Assessment Techniques

The preferred order for examination techniques generally follows: Inspection, Palpation, Percussion, Auscultation, except during abdominal assessments where auscultation precedes palpation.
For rectal examinations, certain positions (like Sims’) should be avoided post-hip surgery to prevent complications.

Examination of Children

Demonstrating equipment before use is crucial for preparing children for examination.
Parents should be allowed to stay with younger children to reduce anxiety.

Patient Positioning for Assessment

Weak patients unable to sit unaided should be positioned in Semi-Fowler's to facilitate examination.
The nurse should choose positions that promote comfort and safety while aligning with the examination requirements.

Auscultation Techniques

The diaphragm of the stethoscope is used to listen to high-pitched sounds, such as bowel sounds, while the bell is necessary for low-pitched sounds like murmurs and bruits.

Body Mass Index (BMI) Categories

A BMI of less than 20 is considered underweight; normal ranges are from 20 to 25; 25 to 29.9 indicates overweight, and BMI over 30 signifies obesity.

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Description

This quiz focuses on the fundamentals of nursing, specifically assessing pain types related to patient injuries. It features multiple-choice questions designed to enhance understanding of pain management principles in nursing practice.